Brand New Patient—Same Old ProblemThis morning it happened again. A patient new to our office came in with the request to have a bite appliance remade, as the old one was fractured and worn, and definitely showing its age. The patient said that it was there to relieve his dental pain, and when he wore it, his teeth were not quite as sore in the morning.

We routinely take photos of all patients, full face and just of the teeth, and when we looked at these, it was obvious that there were notches near the gum lines of the majority of his back teeth. He remarked that it was because of his toothbrush, which has been a soft brush for years. He could not understand why it keep getting worse, no matter what his brushing technique was.

The answer, of course, is that the notching of his teeth has absolutely nothing to do with how he brushes, or how hard the bristles are on his toothbrush. But it has EVERYTHING to do with his bite, and with the soreness of his clenching and grinding at night.

Imagine if you will driving a nail into a board; we all have experienced that. Likewise, we have all experienced what happens when you hit the nail off-center, and it bends. But it does not bend near the head, but rather at exactly the point where it enters the wood, because that is where the forces concentrate. Can flex above the wood, cannot flex IN the wood. Simple enough to understand.

Teeth are exactly the same, although they do not bend. If force is applied to a tooth in a direction the tooth is not designed to resist, that tooth will flex, and the greatest concentration of force will be closest to the gums and bone that support the tooth. This is also in the same exact area where the enamel of the tooth tapers down to a thin dimension as it blends into the softer (and more sensitive) root structure. And so the enamel cannot resist the forces of the abnormal bite, and it flakes off. However, the enamel does not flake off all at once, but rather incrementally, and microscopically. One does not even notice it at first, but, as Ben Franklin famously observed, “Small strokes fell great oaks.” Eventually, the notching appears, as well as a heightened sensitivity in the area.

Time there was when we would routinely fill those notches with composite fillings, and assume that the strength of the bonding would allow the fillings to stay in the tooth. Most of the time, we were wrong. Anything that can break away tooth structure can and will break away restorations. And so no restoration should be expected to last if the CAUSE of the problem is not first resolved.

The fix could be as simple as a bite adjustment, or it could be more complex; it all, of course, depends on the unique bite and reflexes of the individual. But in every instance, the problem must be resolved prior to the final restoration, or the problem will continue.